2. Introduction
• Blepharoptosis, also referred to as ptosis, is
defined as an abnormal low-lying upper eyelid
margin
• The normal adult upper lid lies 1.5 mm below
the superior corneal limbus
3. Introduction
• Classified as congenital or acquired based on
age
• Classification is based on etiology includes
myogenic, aponeurotic, neurogenic,
mechanical, traumatic, and pseudoptotic
7. Simple congenital ptosis
• Abnormality in embryonic development of levator
palpebrae muscle
• Levator muscle usually dystrophic with fibrotic or
fatty tissue replacing healthy muscle fibres
• Poor lid movement
• Lagophthalmos
• Increase fissure height on downgaze
10. Blepharophimosis syndrome
• Other craniofacial abnormalities :
malar hypoplasia ,hypertelorism , fusion of the
eyebrows, poorly developed nasal bridge
• Epicanthus inversus is the most common form
• Inherited as an autosomal dominant trait
• Mutations in the FOXL2 gene located in chromosome
3q23
12. Double elevator palsy
• Association of congenital ptosis and inability to
supraduct the ipsilateral eye
• Motility dysfunction is usually isolated to
superior rectus( defect of the superior division of 3rd
nerve)
• Poor bell reflex often present ( lagophthalmos and
exposure keratitis common )
14. Congenital ocular fibrosis syndrome
• Autosomal dominant condition
• Characterized by Ophthalmoplegia and Ptosis
• Clinical findings range from isolated fibrosis of single
muscle to bilateral involvement of all extraocular muscles
• Clinical manifestations usually present from birth, are
nonprogressive and are limited to extraocular muscles
16. Occulomotor nerve palsy
• ~50% are congenital and result from
thromboembolic vascular disease ,birth trauma,
direct trauma during amniocentesis
• Causes of acquired Oculomotor nerve paralysis in
children :
trauma, inflammation, viral infections and tumors
17. Horners syndrome
• Classic triad of ptosis, miosis and anhidrosis
• Abnormal sympathetic innervation
• Pharmacologic testing of the pupil response to
topical cocaine and hydroxyamphetamine can
determine the location of the lesion
18. Horners syndrome
• Congenital Horner’s syndrome associated with
lighter iris color in the eye with blepharoptosis
(ptosis with ipsilateral heterochromia)
• Levator function is typically normal
• Amount of ptosis is usually 1–3 mm when compared
to fellow eye
19. Congenital Myasthenia Gravis
• Systemic disorder of neuromuscular junction
• Onset of symptoms may occur at birth
(congenital myasthenia) or during childhood
(pediatric myasthenia)
• Nonautoimmune and result from gene
defects affecting ach receptor ion channels or
acetylcholinesterase
20. Congenital Myasthenia Gravis
• Affected infants have weak sucking and crying
responses and may have generalized weakness or
impaired swallowing and breathing
• May be recognized in first 72 h and abates
spontaneously after 2–3 weeks as passively
Transferred myasthenic antibody from the mother is
cleared.
21. Congenital Myasthenia Gravis
• .
Congenital versus adult myeshthenia
Occurs at birth or shortly afterwards
Generalised weakness minimal or absent
Often affects siblings
More frequent in males
Acetylcholine receptor antibodies and immune complex deposition
are absent
should be distinguished from transient symptoms in newborn of
myasthenic mother
22. Marcus Gunn jaw winking phenomena
• Accounting for ~2–13% of congenital ptosis cases
• Marcus gunn ptosis occurs almost always unilaterally, more
frequently on the left
• Usually sporadic without an inherited pattern
23. Marcus Gunn jaw winking phenomena
• Unilateral eyelid movement with the movement of the jaw
• Synkinetic movement results from congenital, aberrant
connection between :
trigeminal nerve ( controlling the muscles of mastication )
and oculomotor nerve ( innervating levator palpebrae
superioris
• When the mouth opened or jaw moved laterally, ptotic eyelid
elevates
25. Aponeurotic
• Contrast to myogenic ptosis, aponeurotic form caused by
defect in aponeurosis of LPS
• Lead to ineffective transmission of force generated by
contracting levator muscle
• Levator function is normal
• Amount of ptosis variable
• Accompanied by a higher-than-normal lid crease
26. Mechanical Ptosis
• Caused by inability of levator muscle to function
properly due to the weight of tumor mass, foreign
body or soft tissue swelling
• Capillary hemangiomas and plexiform
neurofibromas commonly responsible for mechanical
ptosis in children
27.
28. • Pseudoptosis must be differentiated from true ptosis
• Can occur secondary to a number of conditions
Microphthalmos, anophthalmos, enophthalmos,
phthisis bulbi, hypoglobus, contralateral lid
retraction and hypertropia.
31. Mechanical acquired ptosis
• Caused by lid tumors, cicatrix or blepharochalasis
• Both benign and malignant tumors of upper eyelid
and orbit may cause ptosis as a result of increased
weight in the lid
32. Mechanical acquired ptosis
• Cicatricial ptosis is caused by scarring involving
the conjunctiva of tarsus and superior fornix
• Surgical and nonsurgical trauma and
conjunctival shrinkage syndromes (e.g.,
Stevens– Johnson or ocular cicatricial
pemphigoid) account for most cases
33. Myogenic acquired ptosis
• Manifestation of myopathic conditions
involving the levator palpebrae superioris or
myoneural junction
• Chronic progressive external ophthalmoplegia;
Myasthenia gravis
Myotonic dystrophy
34. Neurogenic acquired ptosis
• Dysfunction of the third cranial nerve, which
supplies the levator, or the sympathetic
innervation to Muller’s muscle may cause
neurogenic ptosis
35. Aponeurogenic acquired ptosis
• Most common form of acquired ptosis
• Most often affects elderly persons, can occur in
younger patients as the result of
Trauma
Orbital or eyelid swelling
Blepharochalasis
Prior ocular surgery
Chronic ocular inflammation
Rigid contact lens wear
38. Clinical evaluation of ptosis
History:
• The onset of ptosis,
• Alleviating or aggravating factors,
• Family history of ptosis
• Diurnal variation
• Association with
– Jaw movements
– Abnormal head posture
• History of
– Trauma or previous surgery
– Use of steroid drop/ contact lens wear
• Previous photographs may prove to be of great help
42. Clinical evaluation of ptosis
Putterman method :
• Measurement of distance between middle of
upper lid margin to the 6’o clock limbus in
extreme up gaze (MLD)
• Normal is about 9.0 mm
45. Clinical evaluation of ptosis
MRD 1 Centre of upper eyelid to corneal reflex 4.5 – MRD = ptosis
MRD 2 Centre of lower eyelid to corneal reflex
MRD 3 Centre of upper eyelid to corneal reflex in
Extreme upgaze
(7 – MRD 3 ) x 3 = amount
of LPS resection
MLD Centre of upper eyelid to 6 o clock limbus
in extreme upgaze
(9 - MLD ) x 3 = amount of
LPS resection
47. Clinical evaluation of ptosis
• Grading of ptosis :
SEVERITY AMOUNT OF PTOSIS
MILD PTOSIS 2 MM OR LESS
MODERATE PTOSIS 3 MM
SEVERE PTOSIS 4 MM OR MORE
61. Summary
• Ptosis is caused by weakness of the muscle responsible for
raising the eyelid, damage to nerves that control those
muscles, or looseness of the skin of the upper eyelids
• Drooping eyelid can be caused by the normal aging process, a
congenital abnormality or the result of an injury or disease
• Detail history and examination required for proper
management of ptosis
• Treatment is mostly surgical ,which may be internal or
external approach depending on severity of ptosis
CPEO is also known as mitochondrial encephalomyelopathy with ophthalmoplegia or progressive external ophthalmoplegia. Because it is so often associated with diseases affecting many levels of the neurologic system, it is often referred to as "ophthalmoplegia plus." The main feature is progressive limitation of eye movements, usually with drooping of the eyelids (ptosis). Ptosis may occur years before other symptoms of ophthalmoplegia. Because both eyes are equally involved and because ability to move the eyes lessens gradually over the course of years, double vision is rare. On examination, the eyelids may appear thin. This disease usually begins in childhood or adolescence but may start later.
Thromboembolic disease : congenital rheumatic heart disease, nephrotic syndrome,polycyethemia,protein c protein s deficiency
Congenital tumors : glioblastoma multiforme,astrocytoma,medulloblastoma,primitive neuroectodermal,meningioma,teratoma
Central heterochromia is an eye condition where there are two colors in the same iris; the central (pupillary) zone of the iris is a different color than the mid-peripheral (ciliary) zone, with the true iris color being the outer color.
Heterochromia iridium (two different-colored eyes within a single individual) and heterochromia iridis (a variety of color within a single iris)
Causes of heterochromia :
Inherited trait
Familial heterochromia
Waardenberg syndrome
Glaucoma medications(prostaglandin analogues (latanoprost, isopropyl unoprostone, travoprost, and bimatoprost) Glaucoma (pigment dispersion syndrome)
Inflammation in one eye
Neurofibromatosis
Eye hemorrhage
Foreign body in eye
Eye injury
Siderosis bulbi
Congenital Horner's syndrome
Fuch's heterochromic iridis
Hirschsprung's disease
Incontinentia pigmenti
Parry-Romberg syndrome
transient, potentially lifethreatening
condition resulting from the passive transfer of
immunoglobulin from the mother to the infant
To correct only ptosis : LPS reection
To orrect both jaw wink and ptosis : removal of LPS and frontalis suspension
Defects in innervation occurring during embryogenesis can
lead to neurogenic types of ptosis.
Defects in innervation occurring during embryogenesis can
lead to neurogenic types of ptosis.
Microphthalmia : small eye
Anophthalmia : complete absence of eye
Enophthalmia : eyes that are abnormally shrunken into the sockets
Pthisis bulbi : shrunken, non-functional eye that results from severe ocular disease, inflammation, or injury
Hypoglobus :downward displacement of the eye in the orbit
Hypertropia : misalignment of the eyes (strabismus), whereby the visual axis of one eye is higher than the fellow.
The contour of the lid usually reflects the tumor position, with greater ptosis in the area of the mass
Blepharochalasis is a rare syndrome consisting of recurrent bouts of upper eyelid edema associated with thinning, stretching, and fine wrinkling of the involved skin. The lower eyelids are not commonly involved.
If correction is deemed appropriate, the approach
usually starts with scar revision or excision combined with
grafts of conjunctiva or other mucous membranes
external ophthalmoplegia paralysis of the external ocular muscles.
internal ophthalmoplegia paralysis of the iris and ciliary apparatus.
nuclear ophthalmoplegia that due to a lesion of nuclei of motor nerves of the eye.
Parinaud's ophthalmoplegia paralysis of conjugate upward movement of the eyes without paralysis of convergence, associated with midbrain lesions.
partial ophthalmoplegia that affecting some of the eye muscles.
progressive external ophthalmoplegia gradual paralysis affecting the extraocular muscles, and sometimes also the orbicularis oculi, leading to ptosis and progressive total ocular paresis.
total ophthalmoplegia paralysis of all the eye muscles, both intraocular and extraocular.
MRD 1 is independent of entropion.ectropion or lower lid retraction
In vertical straibismus,MLD is not valid buz the 6 o clock limbal level in upgaze is abnormal due to vertical deviation
Mrd3 is for vertical squint
It is important to leave at least 4 mm of tarsus, however, in order
to avoid destabilizing the eyelid, which can then cause an entropion.
The Putterman procedure involves an internal conjunctivo- Müllerectomy sparing tarsus. The amount of resection that can range from 6.0 mm to 9.5 mm is described by Putterman and is based on the phenylephrine response. Typically 8 mm of conjunctiva and Muller’s muscle are resected above the tarsus.
Button hole incision medially and laterally over lps ,muller ,tarsus and conjunctiva
Severe these tissues from the tarsus
Clamp is reflected superiorly to facilitate dissection of conjunctiva from muller
Excess conjunctiva resected and reamaining attached to superior tarsus border
Once appropriate lid height formed,excess levator resection done
silastic, and the wide-pore, expanded polytetrafluoroethylene (ePTFE) :alternatives to autogenous fascia lata
complications of harvesting fascia lata include an unsightly scar in the thigh region, hematoma formation, keloid formation
and herniation of the muscle belly
The monotriangular method of upper lid fascia sling can be used instead of the more popular bitriangular method. Advantages include less need for fascial tissue, less periocular scar formation and a shorter period of anesthesia.
